Advancement of Surgical Visualization Methods: A Comparison Study between Traditional Microscopic Surgery and a Novel Robotic Optoelectronic Visualization Tool for Spinal Surgery

Moisi MD, Hoang K, Tubbs RS, Page J, Fisahn C, Paulson D, Jeyamohan S, Delashaw J, Hanscom D, Oskouian RJ, Chapman J.Advancement of Surgical Visualization Methods: A Comparison Study between Traditional Microscopic Surgery and a Novel Robotic Optoelectronic Visualization Tool for Spinal Surgery.World Neurosurg. 2016 Nov 8. pii: S1878-8750(16)31147-0. doi: 10.1016/j.wneu.2016.11.003. 

ABSTRACT

INTRODUCTION:

The operative microscope has become instrumental in aiding surgeons during key microdissection with greater safety and detail. An exoscope offers similar detail with improved functionality and greater implications for live-teaching and improved operating-room flow.

METHODS:

Eleven senior neurosurgery residents and fellows performed unilateral, single-level laminotomies on fresh cadavers using an operating microscope and exoscope. Three attending spine surgeons blinded for the visualization technique used then reviewed and graded each decompression. Data points gathered included time of procedure, grading of decompression (1-5), and complications, including dural tear, nerve root injury, and pars fracture.

RESULTS:

Operative times between the two systems were not significantly different (14.9 minutes OM versus 15.6 minutes exoscope p=0.766). Despite high variability between evaluators in assessing complications and adequacy of decompression, there was no significant difference between either system. Post-procedural surveys indicated greater comfort with the exoscope, greater ease of use, and superior teaching potential for the exoscope over the standard operative microscope.

CONCLUSION:

In our simulated operating room model, an exoscope is a valid alternative to the standard operating microscope that affords the surgeon greater comfort with greater teaching potential while maintaining many of the microscopes benefits.

 

Unusual Manifestation of Superior Mesenteric Artery Syndrome in a Female Patient: A Case Presentation

Fisahn C, Moisi M, Umeh R, Sylvester S, Maddali P, Tubbs SJ, Oskouian RJ, Loukas M, Tubbs RS.Unusual Manifestation of Superior Mesenteric Artery Syndrome in a Female Patient: A Case Presentation.Cureus. 2016 Sep 22;8(9):e800.

ABSTRACT

Superior mesenteric artery (SMA) syndrome is a rare clinical entity. We report a female patient presenting with abdominopelvic pain and diagnosed with superior mesenteric artery syndrome. Direct venography revealed a large ovarian varix that was treated with hysterectomy and unilateral oophorectomy. SMA syndrome can have many presentations often with small bowel obstruction. Obstruction of only the ovarian vein with resultant ovarian varix is an unusual presentation.

 

Surgical relevance of the lateral costotransverse ligament in relation to the dorsal root ganglion

D'Antoni AV, Collin PG, Graham RA, Kennedy HM, Ndjatou T, Perez P, Tubbs RS, Loukas M, Kozlowski PB, Mtui EP.Surgical relevance of the lateral costotransverse ligament in relation to the dorsal root ganglion.Anat Sci Int. 2016 Nov 9.

ABSTRACT

The lateral costotransverse ligament, a short band that stabilizes the costovertebral joint, is found in close proximity to the dorsal root ganglion. This ligament is an important surgical landmark during tumor resections or nerve blocks in the paravertebral space. The purpose of this study was to quantitatively and qualitatively describe the morphology of the lateral costotransverse ligament and its relation to the dorsal root ganglion at all levels of the thoracic spine. The thoracic spines of eight embalmed cadavers were dissected bilaterally. The length, width, and thickness of the ligament were measured. The distance from the inferolateral aspect of the ligament to the lateral aspect of the dorsal root ganglion was also measured. Three bilateral groups of lateral costotransverse ligaments, top (on ribs 1-2), middle (on ribs 3-10), and bottom (on ribs 11-12), were compared based on anatomic distinctions between the costotransverse joints, which can influence ligament morphology. Among the three groups, the differences between the length, width, and thickness were not statistically significant. However, the distance from the lateral costotransverse ligament to the dorsal root ganglion differed significantly (P = 0.000), with the middle group having the longest distance, and the bottom group having the shortest distance. This finding can help clinicians and surgeons avoid iatrogenic injuries of neural structures during thoracic spine surgery, or when performing nerve blocks in the paravertebral space.

 

A never before reported variant of the sacrum

Saker E, Oskouian RJ, Loukas M, Johnston JM, Tubbs RS, Conklin M.A never before reported variant of the sacrum.Surg Radiol Anat. 2016 Nov 8.

ABSTRACT

INTRODUCTION:

Several important steps occur in order for the sacrum to develop properly. Embryological derailment can result in several different anatomical variants.

CASE REPORT:

Herein, we report, to our knowledge, the first case of a duplicated sacrum in the sagittal plane.

CONCLUSIONS:

Clinicians and radiologists should be aware of such a finding if found during imaging. We would hypothesize that such a variant occurred near the 29th day of development and probably arose from an error in the HOX gene. To our knowledge, this represents the first reported case.

 

Ulf Fernstrom (1915-1985) and his Contributions to the Development of Artificial Disc Replacements: A Historical Vignette

Fisahn C, Burgess B, Iwanaga J, Chapman JR, Oskouian RJ, Tubbs RS.Ulf Fernstrom (1915-1985) and his Contributions to the Development of Artificial Disc Replacements: A Historical Vignette.World Neurosurg. 2016 Nov 5. pii: S1878-8750(16)31136-6. doi: 10.1016/j.wneu.2016.10.135.

ABSTRACT

INTRODUCTION:

Artificial disc replacements, which serve the function of separating vertebrae to allow for proper spinal alignment, can help treat debilitating low back pain in patients who have failed other conservative methods of treatment. Ulf Fernstrom was the pioneer of artificial disc replacement, and his contribution in the way of Fernstrom "Balls" dramatically altered spinal surgery and technique by demonstrating the proper technique and implant that should be utilized for areas requiring motion in many planes.

HISTORY OF THE ARTIFICIAL DISC:

A Swedish surgeon, Ulf Fernstrom, created his artificial disc inspired by the movement of the hip and knee joints. His implants attempted to restore disc spacing and articulation in patients who had failed conservative measures of treatment. Fernstrom Balls were the first implants of their kind and represent the first attempt at artificial disc replacement. However, many surgeons and researchers questioned Fernstrom Balls, claiming that their lack of elastic properties could potentially damage patients.

CONCLUSION:

Of the wide range of implants currently on the market for the intervertebral disc space, all designs and applications of products stem from the initial discovery made by Fernstrom thus making him a pioneer in disc replacement.

 

Eminectomy for Habitual Luxation of the Temporomandibular Joint with Sedation and Local Anesthesia: A Case Series

Iwanaga J, Nakamura Y, Kusukawa J, Tubbs RS.Eminectomy for Habitual Luxation of the Temporomandibular Joint with Sedation and Local Anesthesia: A Case Series.Case Rep Dent. 2016;2016:2505864.

ABSTRACT

Eminectomy which is one of the popular and most effective treatments for habitual temporomandibular joint luxation was first described by Myrhaug in 1951. There are few reports which described eminectomy being performed under local anesthesia and conscious sedation. We present a case series of habitual luxation of the TMJ treated by eminectomy performed under local anesthesia and conscious sedation and general anesthesia. Five patients were examined and found to have recurrent luxation of the TMJ. The age of patients ranged from 18 to 93 years. Bilateral eminectomy of the TMJ was performed for two patients, and unilateral eminectomy was performed for three patients. Two were examined under intravenous propofol sedation and local anesthesia, while three patients were examined under general anesthesia. One patient died from ileus one month after surgery. The follow-up period except for the case that died from ileus ranged from 12 to 33 months. No recurrent dislocation of the TMJ has been identified. Based on our experience and two other series in the literature, eminectomy with sedation and local anesthesia can be considered and might be a good option in elderly patients.

 

Ectopic arachnoid granulation involving a rare intracranial venous sinus variant.

Umeh R, Loukas M, Oskouian RJ, Tubbs RS.Ectopic arachnoid granulation involving a rare intracranial venous sinus variant.Folia Morphol (Warsz). 2016 Nov 4. doi: 10.5603/FM.a2016.0062.

ABSTRACT

BACKGROUND:

Arachnoid granulations are hypertrophied arachnoid villi, which extend from the subarachnoid space into the venous system and aid in the passive filtration and reabsorption of cerebrospinal fluid. These macroscopic structures have been described in various locations, with the transverse and sigmoid sinuses seen as normal variant s on imaging.

CASE REPORT:

Here we present the occurrence of an enlarged arachnoid granulation at the foramen rotundum where a variant intracranial venous sinus was identified during routine dissection.

CONCLUSIONS:

Variations, such as the one described herein, should be recognized by those who operate or interpret images of the skull base.

 

A previously undescribed variant of the confluence of sinuses

Tardieu GG, Oskouian RJ, Loukas M, Tubbs RS.A previously undescribed variant of the confluence of sinuses.Folia Morphol (Warsz). 2016 Nov 4. doi: 10.5603/FM.a2016.0063.

ABSTRACT

An eight-year old female with a history of chronic headaches and uncertain papilledema was found to have a variant of the posterior intracranial dural venous sinuses on Magnetic Resonance Imaging (MRI) assessment of the brain. Magnetic Resonance Venography (MRV) included in the imaging revealed a circular formation of the confluence of sinuses and absent right-sided Transverse Sinus (TS). The confluence of sinuses is a highly variable structure, however, to the authors' knowledge, a circular confluence of sinuses variant has not been reported in the literature.

 

Historical Perspective of Split Cord Malformations: A Tale of Two Cords

Saker E, Loukas M, Fisahn C, Oskouian RJ, Tubbs RS.Historical Perspective of Split Cord Malformations: A Tale of Two Cords.Pediatr Neurosurg. 2016 Nov 3.

ABSTRACT

INTRODUCTION:

Our appreciation and understanding of what is now known as the split cord malformation (SCM) have a long history. The oldest known example of SCM is from roughly AD 100. Other isolated examples can be found in the large body of work of the pathologists of the 1800s, where the SCMs were found incidentally during autopsies.

CONCLUSIONS:

SCM has a rich history and has intrigued physicians for over 200 years. Many well-known figures from the past such as Chiari and von Recklinghausen, both pathologists, made early postmortem descriptions of SCM. With the advent of MRI, these pathological embryological derailments can now often be detected and appreciated early and during life. Our understanding and ability to treat these congenital malformations as well as the terminology used to describe them have changed over the last several decades.

 

Development of the Anatomical Quality Assurance (AQUA) Checklist: guidelines for reporting original anatomical studies

Tomaszewski KA, Henry BM, Ramakrishnan PK, Roy J, Vikse J, Loukas M, Tubbs RS, Walocha JA.Development of the Anatomical Quality Assurance (AQUA) Checklist: guidelines for reporting original anatomical studies.Clin Anat. 2016 Nov 1. doi: 10.1002/ca.22800. 

ABSTRACT

BACKGROUND:

The rise of evidence-based anatomy (EBA) has emphasized the need for original anatomical studies with high clarity, transparency, and comprehensiveness in reporting. Currently, inconsistencies in the quality and reporting of such studies have placed limits on accurate reliability and impact assessment. Our aim was to develop a checklist of reporting items that should be addressed by authors of original anatomical studies.

MATERIALS AND METHODS:

The study steering committee formulated a preliminary conceptual design and began to generate items on the basis of a literature review and expert opinion. This led to the development of a preliminary checklist. The validity of this checklist was assessed by a Delphi procedure, and feedback from the Delphi panelists, who were experts in the area of anatomical research, was used to improve it.

RESULTS:

The Delphi procedure involved 12 experts in anatomical research. It comprised two rounds, after which unanimous consensus was reached regarding the items to be included in the checklist. The steering committee agreed to name the checklist AQUA. The preliminary AQUA Checklist consisted of 26 items divided into eight sections. Following round 1, some of the items underwent major revision and three new ones were introduced. The checklist was revised only for minor language inaccuracies after round 2. The final version of the AQUA Checklist consisted of the initial eight sections with a total of 29 items.

CONCLUSION:

The steering committee hopes the AQUA Checklist will improve the quality and reporting of anatomical studies. This article is protected by copyright. All rights reserved.

 

Hemivertebrae: a comprehensive review of embryology, imaging, classification, and management

Johal J, Loukas M, Fisahn C, Chapman JR, Oskouian RJ, Tubbs RS.Hemivertebrae: a comprehensive review of embryology, imaging, classification, and management.Childs Nerv Syst. 2016 Nov;32(11):2105-2109. Review.

ABSTRAC

PURPOSE:

The purpose of this paper was to comprehensively review hemivertebrae in regard to their classification, embryology, etiology, diagnosis, clinical manifestations, and management of this developmental anomaly.

METHODS:

This subject review of hemivertebrae was composed after conducting a thorough review of the available literature on this topic using PubMed and other standard search engines.

RESULTS:

Hemivertebrae are incomplete vertebral column segments that can result in congenital scoliosis and be associated with a range of other structural anomalies. Presentations may differ and based on location and classification, treatments may vary.

CONCLUSION:

Hemivertebrae are structural anomalies of the vertebral column that can potentially disrupt the spine's normal curvature. Their clinical impact depends on factors such as degree of segmentation and concurrence with other structural anomalies. It is hoped that this review will provide the clinician who treats patients with hemivertebrae a resource in better understanding this finding and its subsequent pathological effects.

 

Extralaryngeal branching of the recurrent laryngeal nerve: a meta-analysis of 28,387 nerves

Henry BM, Vikse J, Graves MJ, Sanna S, Sanna B, Tomaszewska IM, Tubbs RS, Tomaszewski KA.Extralaryngeal branching of the recurrent laryngeal nerve: a meta-analysis of 28,387 nerves.Langenbecks Arch Surg. 2016 Nov;401(7):913-923.

ABSTRACT

INTRODUCTION:

The recurrent laryngeal nerves (RLN) are branches of the vagus nerve that go on to innervate most of the intrinsic muscles of the larynx. Historically, the RLN has been considered to branch after it enters the larynx, but numerous studies have demonstrated that it often branches before. The wide variability of this extralaryngeal branching (ELB) has significant implications for the risk of iatrogenic injury. We aimed to assess the anatomical characteristics of ELB comprehensively.

METHODS:

Articles on the ELB of the RLN were identified by a comprehensive database search. Relevant data were extracted and pooled into a meta-analysis of the prevalence of branching, branching pattern, distance of ELB point from the larynx, and presence of positive motor signals in anterior and posterior ELB branches.

RESULTS:

A total of 69 articles (n = 28,387 nerves) from both intraoperative and cadaveric modalities were included in the meta-analysis. The overall pooled prevalence of ELB was 60.0 % (95 % CI 52.0-67.7). Cadaveric and intraoperative subgroups differed with prevalence rates of 73.3 % (95 % CI 61.0-84.0) and 39.2 % (95 % CI 29.0-49.9), respectively. Cadavers most often presented with a ELB pattern of bifurcation, with a prevalence of 61.1 %, followed by no branching at 23.4 %. Branching of the RLN occurred most often at a distance of 1-2 cm (74.8 % of cases) prior to entering the larynx. A positive motor signal was most often noted in anterior RLN branches (99.9 %) but only in 1.5 % of posterior branches.

CONCLUSIONS:

The anatomy of the RLN is highly variable, and ELB is likely to have been underreported in intraoperative studies. Because of its high likelihood, the possibility of ELB needs to be assessed in patients to prevent iatrogenic injury and long-term postoperative complications.

 

Can blockage or sacrifice of the middle meningeal artery lead to hydrocephalus?

Tubbs RS, Demerdash A, D'Antoni AV, Loukas M, Kulwin C, Oskouian RJ, Cohen-Gadol A.Can blockage or sacrifice of the middle meningeal artery lead to hydrocephalus?Childs Nerv Syst. 2016 Nov;32(11):2153-2157.

ABSTRACT

BACKGROUND:

The middle meningeal artery (MMA) is often sacrificed during neurosurgical procedures in the region of the pterion. This maneuver, herein, is hypothesized to be a potential reason for the development of postoperative hydrocephalus by injuring the vascular supply to the arachnoid granulations near the vertex of the skull, and thus disrupting their ability to allow for transfer of CSF from the subarachnoid space to the venous system.

MATERIALS AND METHODS:

To test this theory, the middle meningeal artery was isolated at the skull base and injected with India ink. Next, the superior sagittal sinus was opened and the arachnoid granulations inspected.

RESULTS:

All specimens demonstrated ink within the arachnoid granulations indicating that their blood supply is completely or at least partially via the middle meningeal artery. This finding with an illustrative case of surgical cautery of the middle meningeal artery at the skull base with subsequent development of hydrocephalus supports our hypothesis of potential role of iatrogenic MMA injury causing hydrocephalus.

CONCLUSIONS:

Our cadaveric study shows that the blood supply of the arachnoid granulations of the superior sagittal sinus is via the middle meningeal artery. Additional cases of postoperative hydrocephalus following middle meningeal artery sacrifice are needed to support our hypothesis.

 

Forensic clinical anatomy: A new field of study with application to medicolegal issues

Porzionato A, Macchi V, Stecco C, Loukas M, Tubbs RS, De Caro R.Forensic clinical anatomy: A new field of study with application to medicolegal issues.Clin Anat. 2016 Sep 20. doi: 10.1002/ca.22796.

ABSTRACT

Forensic clinical anatomy is a new practical application of the discipline of Clinical Anatomy for ascertaining and evaluating medicolegal questions. In particular, individual anatomy (normal anatomy, anatomical variations, age-, disease-, or surgery-related modifications) can acquire significant relevance in various fields of legal medicine such as child abuse, sudden death, medical responsibility and/or liability, personal injury and damage. Anatomical data of forensic interest frequently arise from the correct application of methods of ascertainment; anatomical methods may then be required for further comprehensive analysis. The rigorous interpretation of anatomical data, derived from the ascertainment phase and analyzed on the basis of pertinent literature, can be pivotal for the correct application of evaluation criteria in various forensic contexts. Clin. Anat., 2016. © 2016 Wiley Periodicals, Inc.

 

The neuroanatomy of depression: A review

Oakes P, Loukas M, Oskouian RJ, Tubbs RS.The neuroanatomy of depression: A review.Clin Anat. 2016 Aug 31. doi: 10.1002/ca.22781.

ABSTRACT

Depression is the most common psychiatric disorder, the number one cause of disability and affects up to 15% of the population. The aim of this review is to present a brief synopsis of the various biochemical imbalances thought to contribute to depression, aspects of anatomy possibly implicated in depression, and treatments related to targeting these specific locales. Multiple neurotransmitters and parts of the brain are involved with the disorder of depression. Although an exact etiology for depression has not been found in most cases, various treatments, medicinal, psychiatric and surgical, exist for this disabling disease. An improved knowledge of anatomical sites involved in patients with depression will help in future treatment modalities. Clin. Anat., 2016. © 2016 Wiley Periodicals, Inc.

 

Endoscopic third ventriculostomy: A historical review

Demerdash A, Rocque BG, Johnston J, Rozzelle CJ, Yalcin B, Oskouian R, Delashaw J, Tubbs RS.Endoscopic third ventriculostomy: A historical review.Br J Neurosurg. 2016 Oct 22:1-5.

ABSTRACT

BACKGROUND:

Endoscopic third ventriculostomy (ETV) has become one of the most common neuroendoscopic procedures.

METHODS:

In this article, we will review the major milestones in the history of ETV development from its early use by Walter Dandy to the techniques currently employed with advanced technology.

CONCLUSIONS:

ETV has become an important technique in the armamentarium of the neurosurgeon. From a meager beginning with few applications, our knowledge of long-term outcomes has evolved. ETV has a rich history and more recently, has had a renewed interest in its use. Our current understanding of its indications is growing and is based on a century of development through trial and error.

 

Herpes Simplex Encephalitis of the Parietal Lobe: A Rare Presentation

Fisahn C, Tkachenko L, Moisi M, Rostad S, Umeh R, Zwillman ME, Tubbs RS, Page J, Newell DW, Delashaw JB.Herpes Simplex Encephalitis of the Parietal Lobe: A Rare Presentation.Cureus. 2016 Sep 16;8(9):e785.

ABSTRACT

A 69-year-old female with a history of breast cancer and hypertension presented with a rare case of herpes simplex encephalitis (HSE) isolated to her left parietal lobe. The patient's first biopsy was negative for herpes simplex virus (HSV) I/II antigens, but less than two weeks later, the patient tested positive on repeat biopsy. This initial failure to detect the virus and the similarities between HSE and symptoms of intracranial hemorrhage (ICH) suggests repeat testing for HSV in the presence of ICH. Due to the frequency of patients with extra temporal HSE, a diagnosis of HSE should be more readily considered, particularly when a patient may not be improving and a concrete diagnosis has not been solidified.